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Standing Committee on Health and Ageing - 17/05/2013 - Adult dental services in Australia

WILSON, Professor David Francis, Head of School, Dentistry and Health Sciences, Charles Sturt University

[14:33]

CHAIR: I invite Professor David Wilson to give evidence. Although the committee does not require you to speak under oath, you should understand that these hearings are formal proceedings of the Commonwealth parliament. Giving false or misleading evidence is a serious matter and may be regarded as a contempt of parliament. Do you wish to make a brief introductory statement before we proceed to questions?

Prof. Wilson : Thank you, Madam Chair. Firstly, although it is late in the day, I would like to rather belatedly welcome the committee inquiry to these conjoint facilities here, in Dubbo. It is wonderful to have a dental inquiry into a dental facility, and the university extends its thanks to the committee for even considering holding the hearing here.

CHAIR: May I interrupt you. I do not like to interrupt people when they are giving evidence, but earlier today I expressed the committee's gratitude for your hosting us here today. Also, we congratulated Charles Sturt University on the fantastic facility they have here, the training and the service that they are providing the community and the integral role they play in partnerships in this area. We really appreciate the support and assistance we have had today.

Prof. Wilson : Thank you very much, Madam Chair. I am not quite sure what the committee would like to hear. I have submitted a document for your consideration. To give our school a context, we are a new school in the Australian dental education context. The school was established through a Commonwealth grant back in 2007-08. The school opened its doors in 2009 to both dental students and oral health therapy students. Oral health therapy students have a scope of practice involving dental therapy in the treatment of children and dental hygiene, which involves the treatment of adults as well.

We are an interesting school and, I guess, different from other schools in some respects. Firstly, our facilities extend across five regional towns in New South Wales. So we start here, in Dubbo, where we have this conjoint facility with Jenny's organisation, and we are very, very grateful for our association because it has worked extremely well. We have a clinic in Bathurst, which is essentially a CSU clinic. We have our main training institute for dentistry in Orange, which is a large dental clinical training facility on the university campus. We then have a similarly large training facility in Wagga, where we train the oral health therapy students. And we have another clinical facility in Albury; it is identical to the one in Bathurst.

Our other fairly unique characteristic is that Charles Sturt University runs its own clinics. We are not in partnership with the state government in terms of the provision of facilities, the paying of facilities, and that, of course, for a university creates its own little issues and so on. Other dental schools use the facilities of state government hospitals to train their students. So we are a bit of an experiment. As I will discuss later, having the ability to move freely and rather independently and where we wish to form associations that are effective and value add to both parties, is, I think, the way to go.

Our purposes are few in number. We feel that the university dental school in its entirety can contribute with time to the alleviation of the well-publicised dental workforce problems in the bush. The university has this mantra: if you train in the bush, you will probably stay in the bush. There is very good evidence from Charles Sturt University from programs such as pharmacy and other health programs that if kids come into university from rural environments they are more likely to stay, whereas if they come from the city they may or may not stay to join the workforce in country areas. That is one of our missions. We believe that we can contribute with time to the dental manpower shortages in rural and regional Australia.

Our other mission, which I believe is extremely important and which the university believes is extremely important, is that we are here to offer improved educational opportunities for kids, children, in rural towns. The evidence is that children educated in rural and regional Australia find it harder to get into city-based health programs; whether it is medicine, dentistry or physiotherapy, it does not really matter. It is harder to get in for whatever reason. Secondly, they do not necessarily adapt well to that training environment. If we can provide an educational opportunity in the environment they grew up in then we believe that those students will become not only happy students but will tend, as I said before, to stay in the bush once they graduate. That is a very important mission for us, to improve the opportunities for rural students in this country, and obviously in this case particularly regional New South Wales.

CHAIR: Thank you very much. On training students from regional New South Wales, do you have a special way of targeting them? Do they get preferential treatment in entering the university? Is there a special approach to get those regional kids to come and study dentistry here as opposed to going to Sydney?

Prof. Wilson : Charles Sturt University has a policy of assigning an additional five per cent, if you like, to a high school student's ATAR score that gives them a leg up when it comes to selection time. Our selection processes into dentistry are a process based upon the student submitting what we call a supplementary application, so they have to provide some documentation which indicates a number of things. One is their motivation to do dentistry. I should add for clarification that when I say dentistry I am also referring to oral health therapy, rather than say dentistry and oral health therapy each time. So we do have a supplementary application process. They indicate motivation. They also indicate, and that can be built upon, evidence of experience. The majority of our students who apply to do dentistry would have a reasonably extensive experience of working with a dentist or in a dental setting before they come to us, so they have been there as observers or working as dental assistants and so on. To us, rightly or wrongly, that indicates the degree of motivation for our profession.

They then need to produce evidence of understanding of health issues in regional and rural Australia. Whilst we do not expect a postgraduate standard essay, we would like to hear some expression of understanding that the student understands that in regional and rural Australia patients experience a different set of health problems and a different set of health accessibility issues that their city cousins do not.

We also interview students in a face-to-face 45-minute interview. We assess a number of things. One of them is basically a confirmation of the evidence of interest in doing health studies, particularly dentistry in this case. It has assessment to assess their degree of empathy and their characteristics as people. That really is what the interview is about. Out of that complex process students get a score and out of that they self-select.

We have only been going four years, five application rounds, but this past year we had close to I think 900 applications for the 40 places we have, so the interest is there amongst Australian youngsters. I should add that not all the students come direct from high school. Some are graduates, some are partway through a graduate program.

CHAIR: You were talking about how Charles Sturt University runs its own clinic. How do you bill for your services? Do you receive any national partnership money? Or don't you bill at all?

Prof. Wilson : The school, as I said earlier on, is a bit unique. We have two service delivery arms. One is through dental students, and I will come back to that in a minute. The other is through a suite of private practices we have. We have private practice suites in each of our facilities and we employ dentists to deliver services to patients on a private practice basis, so that is one side of things. Those private facilities can also be leased by dentists who might wish to operate their practices out of them. In particular, we find that the interest we have in leasing those facilities is in periodic leasing by specialists from, say, Sydney, because we do not have dental specialists in this part of the world—although one day we hope to have them. So we have specialists come up once a week or once a fortnight. That has been tremendous, because it means that patients here, instead of being transferred by their private practitioner down to Sydney with all that that involves in terms of cost and time away from family, can come to Orange or perhaps to Wagga. So that is one side of it.

The other side of it is that dentistry is a little bit unique, because I think we are the only health profession where the students, during their many years of training—in this case five, or three in the case of oral health therapy—actually deliver hands-on service to patients under supervision. So we provide a fair amount of service to patients in that way. The downside is that we cover the cost. Of course, the way that university funding comes to a university, and then from a university down to our lowly school level, means that no consideration is taken of the cost that we incur year after year after year, whereas for, say, a school in the city those clinical costs are absorbed by the state government.

Mr COULTON: If that is the case for your students, how do you source the patients? Is there some sort of caveat attached—'We provide a free service, but it might hurt a bit more,' or something?

Prof. Wilson : No.

Mr COULTON: How does that work, though? I just have an interest.

Prof. Wilson : Obviously, for several reasons, we cannot offer a free service. We work within the environment of our private practitioner background, and we are part of a dental delivery team, I suppose. So, where patients can afford it, we do charge a fee, but that fee is cost recovery for us. So what we try and do is recover some of the costs of the consumables we use from the patients, and we have found a very good patient response to that. Basically, in terms of talking to patients in each town where we exist, we are fortunate in having very supportive media in regional New South Wales. We get frequent requests for radio, TV and print media activities. The other thing we have found is that word of mouth is working. In any country town, word goes around pretty quickly whether you want it to or not. We are getting a lot of word of mouth referrals—or not referrals. Patients turn up because their friend has had a treatment or some such.

Obviously the treatments that we provide have been limited until this year, but we now have fifth-year students in our clinics. So, apart from the very complex stuff that dentists can do, we can pretty much offer the full range of services. We can start with the preventative type stuff and the simple fillings. Students are now doing complex crowns, bridges and extractions. Importantly for this region—again, we are a bit different from other schools—our students are able to be involved in the delivery of partial and full dentures, and in regional and rural Australia that is still a need. Several schools have stopped teaching how to make dentures. We have deliberately put it back into the curriculum because it is a real need. Importantly, we are trying to get our students to realise that they need to know how to do this because they could be stuck out in a fairly small country town where they have to take it from a mouth examination to almost construction of a denture all by themselves, whereas in the city you can do the early bits and the rest goes to a dental technician to construct.

Mr COULTON: Is it hard to match the needs of your students? To a certain degree, the types of patients that would come through would be rather random, I would imagine. You would deal with who comes in every day. It would be a variety of things. Is it a challenge in a smaller community to get the variety or the mix of treatments that you might want to offer?

Prof. Wilson : Surprisingly not. But I take the point that you are making—we do not let every patient go to a student. There are some patients who require more complex care, or who require careful care because of their medical history. Nowadays many patients come in to us, particularly elderly adults, with a pharmacy of medications in their pockets, and some of those cases are not good for junior students to treat. But in general we are very happy with the types of experiences our students can have. I might just expand on that: several people today have commented upon our working relationships with one another, whether it is the local area health network, or Bila Muuji, or the Royal Flying Doctor Service. These sorts of outreaches that we are undertaking in conjunction with our partners are affording tremendous additional opportunities for students. So if they are not getting it, say, in the Orange clinic, they will get it by doing work with the local area health network, or with the flying doctors or with other experiences.

Mr COULTON: Now that you have got the fifth years coming through, I am just wondering how they are going with the pathway into practice. Is that something that you are helping them with? Are they finding employment, or are they going to need some form of assistance to get established?

Prof. Wilson : We have no experience in that yet so my answer is going to be partly hypothetical, I am afraid. But basically, the way we have designed the fifth year program is that it is sort of a mini-practice experience. We send the students out for 24 weeks, so they go out into what you might call real world dentistry, in our clinics admittedly but working with tutors who may be local dentists or with local area health network supervisory staff, and it is there that they get a fairly quick waking up as to what real practice is about—whereas if they are training in Wagga or in Orange, they are allowed to have fairly long appointments. They might have an hour-and-a-half appointment to do a mouth exam and a procedure, or just to do a mouth exam. When they are out on placement they are expected to conform—with time; they are not pushed into it—to what is basically a private practice type routine, so you are looking at 45-minute appointments and at proper record keeping and so on.

In terms of the future of our present crop of students, the pleasing thing that I have determined quite recently is that the greatest majority do want to be in rural and regional Australia. I did a straw vote recently, on paper, and 30 out of 32 are expressing strong interest in staying in regional Australia. Now even if we get two thirds of those staying, that will be a wonderful outcome for the university and for the region, and I think for the government who initially contributed the funds to make it all happen.

Later in the year, we are having a week-long, sort of employment fair for the students. That is in Orange, and we will bring in private practitioners, we will bring in the Dental Association and we will bring in the health funds, who will explain what opportunities there are—and hopefully we can bring in the armed forces too, because they are a great source of employment—and that way we will open up opportunities for students. We also hope to keep a couple of students ourselves, if we can.

Mr LYONS: Thank you very much for joining us this afternoon, David. During your opening statement you talked about this being unique, and a bit of an experiment. Just to give us some background, where did the concept of this model come from? Who visualised it? How did it come to fruition? Is it being monitored for success? I guess with you saying that 900 people applied for 40 spots, that speaks for itself—it is successful. If it is being monitored, who is monitoring it? And, if it is such a good concept model, can we see it being rolled out across the country?

Prof. Wilson : Okay. In terms of who conceived of this model, it was before I came to this university so I am not sure how it actually evolved. But a person who was instrumental in making it all happen by working with state and federal governments was Professor Mark Burton, who was in the university here. He did a marvellous job, I think, working with the community and with state and government politicians to convince them of the need for and wisdom of establishing this in regional New South Wales. So I think a fair chunk of credit goes to him because he also drove the development process of the facilities, and instead of putting it all in one town, which is the way most schools are—so it is in Sydney or in Adelaide or Melbourne—he had this vision of it being across the state. So we have sort of north-south delivery of services and access to education by students.

Mr LYONS: So is the government saying, 'This is working; we need to develop this further across the nation'?

Prof. Wilson : I am not aware of that at all. And obviously it is a fairly sensitive issue. We are, along with James Cook, the youngest kid on the block. The James Cook model is a bit different from ours; it is rural but they also work with the state government to establish and run clinics.

Time will tell, but obviously we are monitoring it. I can tell you that the finance department in the university is monitoring it, in terms of cost and so on. But I am very happy with it. I have worked in several dental schools around the world, and this is a really exciting model and I think we have the staff to make it a success. We have our alliances with our partners, as has already been talked about today; that will certainly help make it a success. And we have a university that is behind us, which is really good.

Mr LYONS: From what I have seen it is a great concept, but the fear I see is that, as your program seems to be so good that it will give a good skill level to the graduates, some of the city-based practices might want to start poaching CSU graduates because the quality of the graduates is so good they will be lost to the rural areas. Do you have a fear of that?

Prof. Wilson : Yes; they will go to the city, I think, for a while. But history seems to tell us that they may go over to the city for a while but they will come back to where home was or where their roots were. That is a generalisation and a bit trite, I suppose, but I think that will happen.

One of the interesting side-effects of our program—and this has really intrigued me—is that we do have students who went through high school in the cities and joined us back in 2009-10 as first year students, and a significant number of them have undergone a life change. I have had kids tell me they do not want to go home for vacation; they want to stay here. That, to me, is quite significant. So whatever it is about regional Australia or regional New South Wales, it is creating a change in them. So, while I do not have the data yet, I believe that we will retain some of those city kids directly from graduation, provided we have the jobs for them. Of course, we are all working hard on that. There are opportunities out there. I think young people are probably far more flexible than people of my generation in terms of what they will accept as a job. Young graduates may have two or three jobs in different parts of the region rather than just being stuck in the one practice.

Mr LYONS: Do you think health based infrastructure like this in regional or large regional towns like this would contribute to keeping people in the rural areas?

Prof. Wilson : Yes, I believe so. To expand upon that, we are across this region of New South Wales—Dubbo down to Albury—but we are also talking, through the school, with mid-north areas, like the Aboriginal medical service in Kempsey, where some facilities have been built by the state government. But we are talking about trying to codevelop additional facilities up there. Earlier today someone alluded to the fact that you have a building like this, which is an alliance between the university and the Commonwealth through the state government, and we are talking about whether it would be possible to do the same thing up there because there is no question that, with the population base up in that part of the world, additional dental facilities would be not only desirable but extremely productive and useful and would also offer additional facilities to our young students to join programs.

Mr LYONS: What does it cost—what is your overall spend?

Prof. Wilson : In the school?

Mr LYONS: Yes.

Prof. Wilson : It is hard to determine that because our school is a school of dentistry and health sciences, so in my school we have dentistry, oral health therapy, all the radiation sciences, nutrition and dietetics. I have even got astrophysicists.

Mr LYONS: But you would have cost centres.

Prof. Wilson : Not really at this stage. The way the university budgetary system works is different from what you are alluding to, so I am sorry I cannot give you that figure.

Mr LYONS: I have worked in health for 20 years and I think that at Launceston General there are eight orthopaedic surgeons, they all do some training, but the biggest influence was partnering, so I just give you the tip if you want to keep them in a regional area. I think it is a wonderful school. I had a look at Bendigo; it was not operating at the time, but there is a huge facility there as well. If we want to provide services to communities we have got to put the training in those communities, no doubt about that.

Prof. Wilson : Yes, I think that is a self-evident fact.

Mr COULTON: I just have a comment. I want to thank David for his part in making today happen. We had a couple of conversations some time ago and I was very pleased that his influence enabled the university to be involved, so thank you very much.

CHAIR: That was a really important comment. We all thank you.

Prof. Wilson : Thank you.

CHAIR: You have talked a little about the training that is given. What role does prevention have in the course and within the university to get that message out into the community?

Prof. Wilson : We are an educational institution primarily and the preventative message is inbuilt into our curriculum from year 1 to year 2, as it is for oral health therapy. Of course, oral health therapists are prime deliverers of oral health promotion to the community, either directly or by their relationships with other care workers, Aboriginal care workers and so on. The dental students are trained in that. The effectiveness of preventative service, though, is very hard to measure. It does not matter what health issue it is, whether it is general health, a cancer or oral health, I think it is only going to work if you can get the patients motivated and get them to understand what it does for them personally, because we are all pretty selfish individuals—we will do something that will benefit us, mostly.

In the case of dentistry, if you can fix up a patient who has bad teeth, bad oral health, sometimes a light goes on and they decide, 'Maybe what they're talking about is correct—I'm now pain free, I have got teeth I am happy with,' so therefore they will therefore engage with a preventative program, whereas they are unlikely to if they have got bad teeth at the time they get the preventative message. That is just a personal view. Obviously we and the profession will keep pushing the standard preventative messages but, as Sandra said before, it is hard to measure that stuff. But, yes, it is one of the arms of our training program.

CHAIR: Do you do any direct programming in the general community?

Prof. Wilson : We are just beginning that, we have only got students this year into our fifth-year program. There are a couple of things happening that we are quite excited about. One is our future interactions with aged-care facilities and so on. At 5th year our students do a block of curriculum which is called gerodontics and special needs dentistry. Part of that will be, we hope, some practical hands-on experience in a nursing home or an aged-care facility where they are working with the care workers, not necessarily delivering dental services but learning the dental issues associated with the care of the elderly, who often put their dentures in their pockets or whatever. There are things like that happening. We also have an internal program beginning, the name of which I have forgotten. What is the name of that program? SpICE—the university has a SpICE program. Do not ask me what the acronym means, but it is to do with community engagement for not only dental students but students across the different courses at the university. They engage with the community to try to solve some problem. It may be a health problem, it may be delivering a preventative message, or it may be solving a little social problem, depending on the students involved. That is happening. We do get our students volunteering, too, during the break time. We have discovered our students do quite a bit of volunteer work overseas, some of them, and we have a formal overseas program through a thing called CSU Global. The university has a policy that 10 per cent of its graduates will have had, by the time they graduate, an overseas educational experience.

CHAIR: That is all faculties.

Prof. Wilson : Yes. So we have engaged with that. We are developing our ability to have direct interactions with the community other than in a service context.

CHAIR: The final question I have for you relates to the interaction between the different disciplines like dental hygienists, dental students, dental technicians and dental prosthetists—how they all interact within the training environment and the implications of the interaction with different levels of government as well.

Prof. Wilson : Okay. In terms of our particular school, interactions between dental students and hygienists only occur during placement time—so for example, at the moment, we should have hygiene students here. I have checked and we will have our students back here just after July, so there will be interaction there. We do not have BOH students coming to Orange this year but normally we do. The tyranny of distance is a barrier to early interaction between those two groups of students so most of it occurs on placement at this moment in time.

In terms of other branches and aspects of dentistry, we do not have a dental technology training program in our school but we have dental technologists who work with our students. They are a very important teaching and service-provision resource for us and the school.

CHAIR: And government—the other part of my question was about the levels of government working together within the university.

Prof. Wilson : Could you try to reframe that so I can answer it?

CHAIR: Sorry. I talked about the disciplines and then I asked for a similar response in relation to the interaction of both the state and federal governments with the university. I suppose with the state you would be getting your interaction with the health service. How does that interact with the Commonwealth training? If you could share with the committee how you have both levels of government working together in an environment providing both training and services.

Prof. Wilson : Thank you for that explanation. It is on record here, I hope, but I will reconfirm that the dental training program and other therapy programs rely almost exclusively on the interaction between the Commonwealth government and the state government and support from both. One of the things that is exciting to me that has hit the school is that, this year, we have been able to engage with the state government through the oral health advisory group, which is to do with the Commonwealth's delivery of the money that is coming under these different programs.

CHAIR: The National Partnership Agreement, yes.

Prof. Wilson : Yes, the national partnership. Our first big achievement was to sign up with them to help them with their adult waiting list plan. We have signed SLAs through that process just recently. That is exciting for us. I would hope our engagement with them might also lead to other developments. Basically, we are new boys on the block—we are not entirely familiar with the processes of state and federal Commonwealth governments but we have an excellent working relationship with the Centre for Oral Health Strategy in the state and we are already talking about ways in which we could interact with them in the future in terms of the child dental plan. You mentioned flexibility and also infrastructure money, so we will see where that leads. But yes, I think there are exciting opportunities. Both state and Commonwealth governments should be congratulated for their initiative in doing this because, by allowing us to interact directly at that level, it is enormously successful. It cuts out a lot of the steps on the pathway. Sometimes we succeed and sometimes we fail, but at least we have the opportunity to get in there and put our case.

CHAIR: Thank you. Any other questions? No. Can I thank you very much for your evidence, your submission and the role you have played today.

Prof. Wilson : Thank you very much.